Antimicrobial resistance is one of the three greatest threats to human health, according to the World Health Organization. This threat results from the increasing incidence of multidrug-resistant pathogens, diminishing development of new antimicrobials, and the inappropriate use of antimicrobials. In light of this urgent threat and the potential to improve the use of antimicrobials, the CDC recommends that US acute care hospitals support an antimicrobial stewardship program (ASP). ASPs are quality improvement initiatives with the goal of optimizing antimicrobial use to achieve best clinical outcomes, improve patient safety, limit the selective pressure that drives the development of resistance, and reduce excessive costs. However, it is unclear how to effectively evaluate, and therefore optimize, an antimicrobial stewardship program. Outcome measures for antimicrobial stewardship efforts have not been well-defined or tested. No multicenter, longitudinal studies of ASP optimization exist. The Duke Antimicrobial Stewardship Outreach Network (DASON), a collaborative group of community hospitals that share data, educational materials, and consultative services, provides a unique opportunity to study how programmatic development evolves in community hospitals. The goal of the proposed study is to develop, implement, and evaluate the utility of measures of impact important in assessing the success of ASPs. The specific aims of the proposal are the following: 1a) Define antimicrobial stewardship measures of impact to identify areas in need of intervention at community hospitals, 1b) Define the current state of antimicrobial utilization, antimicrobial resistance, and existing antimicrobial stewardshi activities in a cohort of community hospitals, and 2) Quantitatively assess the effect of data feedback on patient outcomes, ASP goals, and activities. Completion of these aims will provide 1) the most complete analysis of antimicrobial use, resistance, and ASP activities in community hospitals to date, and 2) measures of impact for ASPs that have demonstrated utility and effect on program development. Measures developed during this study will be used in future investigations of specific stewardship interventions as well as national efforts to optimize antimicrobial use. The PI's long-term goal is to become an independent clinician-scientist performing health services research in antimicrobial stewardship. To achieve this goal, the PI will acquire advanced statistical skills and knowledge of health services research methods that will enhance her existing expertise in healthcare epidemiology. Close oversight from her co-mentors, didactic coursework, tutorials with two internal advisors in areas of need, two external expert collaborators in antimicrobial stewardship, and completion of the proposed study will provide the necessary elements for her to achieve this goal.